Every finding on record at Nova Health and Rehab

Based on staff interview and clinical record review the facility staff failed to correctly code a minimum data set (MDS) assessment for 1 of 3 closed record reviews, Resident #86. The findings included: For Resident #86, the facility staff coded the MDS as acute hospitalization when the resident discharged home. Resident #86's face sheet listed diagnoses which included but not limited to hypertension, heart failure, dementia, and anxiety. Section A (Identification Information), subsection A2105 (discharge status) of Resident #86's discharge assessment coded the resident as being discharged to Short-Term General Hospital (acute hospital). This MDS has an assessment reference date of 04/12/24 and listed the discharge as unplanned. Resident #86's clinical record was reviewed and contained a nurse's progress note dated 04/12/24 which read in part, Res (resident) daughter arrived at facility and was upset about a bill they owed the facility. Stated she was taking her mom home and that she was not paying this bill. Res was educated on the importance of not leaving the facility AMA (against medical advice). Res and daughter verbalized understanding. Res signed AMA and daughter exited the facility with res and all res. belongings. Dr. (name omitted) aware of situation. Surveyor spoke with the MDS coordinator on 06/27.24 at 9:15 am regarding Resident #86's discharge status. Surveyor asked MDS coordinator if resident was hospitalized , and MDS coordinator stated they were not. Surveyor then asked MDS coordinator if the MDS was coded correctly, and MDS coordinator stated that it was not, and they would fix it. The concern of not coding the resident's MDS correctly was discussed with the administrator, director of nursing, and regional nurse consultant on 06/27/24 at 1:40 pm. No further information provided prior to exit.

Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than 5%. There were 2 medication errors in 26 opportunities for a medication error rate of 7.69%. These medication errors affected Resident #20 and #82. The findings included: 1. For Resident #20, the facility staff failed to administer the probiotic, Lactobacillus Acidophilus as ordered by the medical provider. Resident #20's diagnosis list indicated diagnoses, which included, but not limited to Vascular Dementia, Essential Hypertension, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Constipation, and Chronic Kidney Disease Stage 3. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 5/24/24 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating the resident was moderately cognitively impaired. On 6/26/24 at 8:57 AM, surveyor observed Licensed Practical Nurse (LPN) #2 prepare and administer Resident #20's morning medications. A reconciliation of the administered medications with the current provider orders revealed a current order for Lactobacillus Acidophilus one (1) capsule once daily for gut health at 9:00 AM. Surveyor did not observe LPN #2 administer Lactobacillus Acidophilus. Surveyor returned to LPN #2 at 10:10 AM and inquired about the Lactobacillus Acidophilus, LPN #2 stated they did not give the medication as it did not appear on the MAR (Medication Administration Record) screen for administration. LPN #2 stated some medications were not pulling to the MARs with the new system and the facility was having daily conference calls with the system provider. On 6/26/24 at 4:33 PM, the survey team met with the Administrator and Director of Nursing and discussed the concern of the facility medication error rate of 7.69% and Resident #20 not receiving medications as ordered. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/24. 2. For Resident #82, the facility staff failed to administer a Lidocaine 5% medicated patch to the resident's leg as ordered by the medical provider. Resident #82's diagnosis list indicated diagnoses, which included, but not limited to Cerebral Infarction, Hemiplegia and Hemiparesis, Peripheral Vascular Disease, and Alzheimer's Disease. The most recent minimum data set (MDS) with an assessment reference date (ARD) of 4/26/24 assigned the resident a brief interview for mental status (BIMS) summary score of 3 out of 15 indicating the resident was severely cognitively impaired. On 6/26/24 at 9:07 AM, surveyor observed Licensed Practical Nurse (LPN) #2 prepare and administer Resident #82's morning medications. A reconciliation of the administered medications with the current provider orders revealed a current order for Lidocaine 5% medicated patches to be applied to the leg and lower back once a day at 9:00 AM. Surveyor observed LPN #2 apply a Lidocaine patch to Resident #82's lower back only. Surveyor returned to LPN #2 at 10:12 AM and inquired about the order for a Lidocaine patch to the resident's leg. LPN #2 stated Resident #82 had been refusing the patch to their leg, but LPN #2 acknowledged they did not ask the resident if they wanted the Lidocaine patch applied today. On 6/26/24 at 4:33 PM, the survey team met with the Administrator and Director of Nursing and discussed the concern of the facility medication error rate of 7.69% and Resident #82 not being offered a Lidocaine patch to their leg as ordered. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/24.

Based on observation, staff interview, and facility document review, the facility staff failed to store all drugs and biologicals in locked compartments on 1 of 2 nursing units, Unit 1. The findings included: For Unit 1, the facility staff failed to lock an unattended medication cart. On 6/26/24 at 8:46 AM, during a medication pass and pour observation, Licensed Practical Nurse (LPN) #1 prepared medications for a resident, entered the resident's room and administered the medications while leaving the medication cart in the hall, unlocked, unattended, and out of direct sight. When LPN #1 returned to the medication cart, they acknowledged the cart was left unlocked. Surveyor requested and received the facility policy titled General Dose Preparation and Medication Administration with a revision date of 4/30/24 which read in part, .7. Facility should ensure that medication carts are always locked when out of sight or unattended . On 6/26/24 at 4:33 PM, the survey team met with the Administrator and Director of Nursing and discussed the concern of LPN #1 leaving a medication cart unlocked and unattended. No further information regarding this concern was presented to the survey team prior to the exit conference on 6/27/24.

Based on observation, staff interview, and facility document review facility staff failed to ensure food was stored under safe and sanitary conditions in one of one walk-in refrigerators and one of one dry storage rooms. The findings were: During the initial kitchen tour on [DATE] at 2:03 p.m., accompanied by one of the facility's cooks, expired items were found within the walk-in refrigerator and dry storage room. One unopened box of individual sour cream packets had a printed expiration date of [DATE], one unopened container of Ricotta cheese had a printed expiration date of [DATE] In the dry storage room there were 2 (two), unopened, opaque, one-quart paper containers of honey thick lemon water with a printed expiration date of [DATE]. The cook stated that he/she must have missed those two containers when he/she checked for expired dates. The facility's dietary manager (DM) arrived on [DATE] at approximately 2:45 p.m. as the initial tour was concluding. On [DATE] at approximately 2:50 p.m. the DM acknowledged the sour cream was expired and threw the box away. The DM acknowledged the cook had reported the 2(two) one-quart containers of honey thick lemon water had expired. On [DATE] at 4:05 p.m., when asked about the facility's process of observing for expiration dates on food/products, the DM stated the whole kitchen staff looked for expiration dates on food products. The DM reported typically the night cook went through the refrigerators and added that looking for expired products was everybody's responsibility. After the surveyor requested a policy on the facility's process for managing food expiration dates, on [DATE] at 1:45 p.m., the DM provided 1 (one) untitled piece of paper with typed information describing the process for receiving food products. The document did not identify the facility or corporation or where it originated. The document read in part, Dating/Labeling/Rotating: Everything that is delivered is to be clearly marked with a marker with the received date. This is the only ways [sic] we can prove rotation. FIFO-first in first out. Everything is to re[sic] be rotated so the new is to the back and the older gets pulled to the front so it gets used first. When you open any item it is to have an Open [sic] date and a use by date. Example: I open pudding and put it in a half gallon container, I will put a O or opened ,d+[DATE] EXP or UB ,d+[DATE] . Both the administrator and director of nursing (DON) were notified of the above observations on [DATE] at 4:45 p.m. during an end of day meeting with the survey team in the conference room. There was no further information provided prior to the exit conference.

Based on staff interview and facility document review, the facility staff failed to implement the COVID-19 vaccination process in the attempt to prevent the transmission of COVID-19 for 2 of 93 employees. The staff vaccination rate was 97.8%. The findings included: The facility policy titled, Employee COVID-19 Vaccination Policy with a revision date of 01/27/22 read in part, The goal of the facility is to safeguard the health of our employees and their families; our residents and visitors; and the Facility at large from COVID-19. All employees are required to receive a FDA authorized and/or approved COVID-19 vaccination as required by the Interim Final Rule of the Centers for Medicare Services (CMS) regarding healthcare staff COVID-19 vaccination, unless a reasonable accommodation from this requirement due to disability, medical condition, or sincerely held religious belief, practice or observance requested and approved . The facilities contingency plan for unvaccinated staff read in part, Employee vaccination rate is not at 100% compliance at this time. Our goal is to be 100% by 3/27/2022 unless the employee has received an exemption .we will continue to educate/encourage unvaccinated staff members to try to take the vaccine and that they understand that they will not have employment at this facility if they do not comply with the mandate. On 02/01/22, the facility provided a copy of their COVID-19 Staff Vaccination Status for Providers matrix. Employee #1 and employee #2 were marked as Not vaccinated without exemptions/delay. As of 02/03/22, the facility had no positive COVID-19 resident's in house and 3 current positive staff. These staff were currently not working at the facility. 1. Employee #1, was a therapy employee-hire date 06/05/2019. Employee #1 had requested a Religious Accommodation from COVID-19 Vaccination this exemption was denied. The facility provided paperwork to indicate the employee had requested this exemption on 11/15/21. The company denied the exemption on 11/16/21 as The accommodation would cause an undue hardship based on imposing a direct threat to the health and safety of the employee and those living and working in the workplace. On 02/03/22 at 9:56 a.m., employee #1 stated their exemption was denied as they were a direct threat. Employee #1 stated they worked directly with residents of the facility, generally worked with from 4 to 8 residents daily, and they did not attempt to appeal the exemption, as they did not know that was an option. Employee #1 stated the company seemed very resolute in their decision, they had been educated multiple times on the COVID-19 vaccine, they wore an N95 face mask and eye wear when working with the residents, and they were being tested twice a week by the facility for COVID-19. The facility provided a negative rapid test for this staff dated 02/03/22. On 02/03/22 at 2:40 p.m., the DON stated they would continue to provide education in regards to the COVID-19 vaccine and continue to schedule vaccine clinics. No further information regarding employee #1 and the COVID-19 vaccine was provided to the survey team prior to the exit conference. 2. Employee #2, was a PRN (as needed) therapy employee-hire date 04/08/2014. This employee tested positive for COVID-19 on 01/22/22 and was not currently working in the facility. On 02/03/22 at 10:51 a.m., the DON (director of nursing) stated employee #2 last worked with residents of the facility on 01/15/22, was at the facility to complete training on 01/20/22 and 01/22/22, tested positive for COVID-19 on 01/22/22 and had not worked since. The DON stated this staff person would have to be vaccinated before they were allowed back in the building. When asked if there was a reason this staff person was not vaccinated the DON stated they were not sure. On 02/03/22 at 11:03 a.m., director of rehab stated they did not know why staff #2 was not vaccinated. On 02/03/22 at 2:40 p.m., meeting with the DON and administrator, the DON stated employee #2 was eligible for the COVID-19 vaccine, they would continue to provide education in regards to the COVID-19 vaccine and continue to schedule vaccine clinics. No further information regarding employee #2 and the COVID-19 vaccine was provided to the survey team prior to the exit conference.

Based on clinical record review, staff interview, facility document review, the facility staff failed to notify the physician of changes in Resident condition for 2 of 24 Residents in the survey sample, Resident # 18 and Resident #76. The findings included: 1. The facility staff failed to notify the physician of low blood sugar level for Resident # 18. Resident # 18 was a [AGE] year-old-female that was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 18 was reviewed on 9/5/19 at 9:30 am. The most recent MDS (minimum data set) assessment for Resident # 18 was a quarterly assessment with an ARD (assessment reference date) of 6/12/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 18 had a BIMS (brief interview for mental status) score of 5 out of 15, which indicated that Resident # 18's cognitive status was severely impaired. The current plan of care for Resident # 18 was reviewed and revised on 6/7/19. The facility staff documented a focus area for Resident # 18 as, Resident has increased nutrition hydration risk related to: [MEDICAL CONDITION], [MEDICAL CONDITIONS]([MEDICAL CONDITION] reflux disease), diabetes with ketoacidosis without coma, [MEDICAL CONDITION], acute pancreatitis without necrosis or infection, weight loss, sig (significant) weight loss noted. Interventions included but were not limited to, Medicine kit for low blood sugars as ordered. Resident # 18 had current orders that included but were not limited to, [MEDICATION NAME] Emergency Kit 1 mg (milligram) Inject 1 application intramuscularly as needed for low blood < (less than) 50 may inject [MEDICATION NAME] emergency kit if blood sugar <50 and resident is unable to take PO (by mouth) intake, which was initiated by the physician on 3/29/18. On 9/5/19 at 2:52 pm, the surveyor observed the following notes documented in the progress notes for Resident # 18. An eMAR (electronic medication administration record) medication administration note was documented on 9/1/19 at 12:30 am. The note was documented as, FSBS as needed for DM hypoglycemic, thrashing in bed blood sugar 47. An eMAR medication administration note was documented on 9/1/19 at 12:37 am. The note was documented as, [MEDICATION NAME] emergency kit 1 mg application intramuscularly as needed for low blood <50 may inject [MEDICATION NAME] emergency kit if blood sugars <50 and resident is unable to take PO intake blood sugar 47. The surveyor reviewed the clinical record further for Resident # 18 and did not observe any documentation that reflected that the physician had been notified of Resident # 18 having a blood sugar of 47 on 9/1/19. On 9/6/19 at 2:35 pm, the regional vice president of operations, administrator, and director of nursing were made aware of the findings as stated above. The surveyor asked the director of nursing if she expected the nursing staff to notify the physician if a Resident had a low blood sugar that required the use of [MEDICATION NAME]. The director of nursing informed the surveyor that she did not expect the nursing staff to notify the physician each time Resident # 18 had a low blood sugar reading because Resident # 18 had a history of [REDACTED]. The surveyor requested to see the facility diabetic care policy. On 9/6/19 at 4:40 pm, the facility staff provided the surveyor with a copy of the Care of the Diabetic Patient policy. The policy contained documentation that included but was not limited to, .Note: Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention. [DIAGNOSES REDACTED] (blood sugar below reference ranges). Signs and symptoms of [DIAGNOSES REDACTED] usually have a sudden onset and may include the following: b) Restlessness and or muscle twitching j) (more severe) stupor, unconsciousness and or convulsions If these or other abnormal conditions exist, notify the physician. On 9/6/19 at 5:20 pm, the regional vice president of operations, director of nursing, and administrator were made aware of the findings as stated above. The survey team provided the opportunity for the administrative team to submit more documentation to dispute the deficient practice of not notifying the physician of Resident # 18's low blood sugar of 47 on 9/1/19. The administrative team reported that they had no further information regarding this issue to submit to the survey team. 2. The facility staff failed to notify the physician when Resident #76 repeatedly refused to have weight obtained as ordered by the physician. Resident #76 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/22/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 4 out of a possible score of 15. During the clinical record review on 9/5/19, the surveyor noted the physician had ordered for Resident #76 to obtain a daily weight. Resident refused to have weights obtained on the following dates: 8/14/19, 8/18/19, 8/19/19, 8/21/19, 8/22/19 and 8/23/19. The resident had been readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 9/6/19 at 10:30 am, the surveyor notified the ADON (Assistant Director of Nursing) of the above documented findings. The surveyor asked the ADON if the physician had been notified of the resident refusing daily weights. ADON stated, No he wasn't. The surveyor asked if this was something that need to be reported to the physician due to the resident having a hospitalization for congested heart failure. The ADON stated, Yes, I expect the staff to notify the physician of the resident refusing daily weights due to the resident returning back to the facility on [DATE] with the [DIAGNOSES REDACTED]. The surveyor notified the administrative team of the above documented findings on 9/6/19 at approximately 3:30 pm in the conference room. No further information was provided to the surveyor prior to the exit conference on 9/6/19.

Based on observation, staff interview, Resident interview, family interview, and clinical record review the facility staff failed to review and revise a CCP (comprehensive care plan) for 1 of 24 Residents, Resident #28. The findings included: For Resident #28 the facility staff failed to revise the care plan for Resident has increased nutrition/hydration risk . Resident #28's face sheet listed an admission date of [DATE] and a readmission date of [DATE]. The Resident's [DIAGNOSES REDACTED]. Resident #28's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) 06/28/19 assigned the Resident a BIMS (brief interview for mental status) score of 8 out of 15 in section C, cognitive patterns. Section G, functional status, coded the Resident as needing extensive help of one-person physical assist in the area of eating. Resident #28's CCP was reviewed and contained a care plan for Resident has increased nutrition/hydration risk . Interventions for this care plan included Feed Resident all meals x1 assist. This intervention was initiated on 07/22/19. The physician's orders [REDACTED]. [REDACTED]. This order was discontinued on 07/19/19. Surveyor spoke with Resident's daughter on 09/06/19 at approximately 8:25 am. Resident's daughter stated during Resident last hospitalization the physician recommended the Resident have feeding assistance. The Resident's daughter stated that she did not think this was being done. Surveyor spoke with CNA (certified nurse's aide) #2 on 09/06/19 at approximately 8:45 am regarding Resident #28's feeding assistance. CNA #2 stated that Resident feeds himself and the she will ask him if he wants/needs help when she goes back to pick up his tray. Surveyor spoke with DON (director of nursing) on 09/06/19 at approximately 10:10 am regarding Resident #28. DON stated that Resident feeds himself and staff will offer to assist him if he does not eat. DON also stated that Resident does not like to be fed. Surveyor spoke with the MDS coordinator on 09/06/19 at approximately 2:25 pm regarding Resident #28. MDS coordinator stated that Resident has an order for [REDACTED]. The concern of not reviewing/revising the Resident's CCP was discussed with the administrative team (administrator, DON, regional vice-president of operations) during a meeting on 09/06/19 at approximately 2:35 pm. No further information was provided prior to exit.

Based on observation, staff interview, Resident interview, family interview, clinical record review and facility document review the facility staff failed to provide ADL (activities of daily living) care for 1 of 24 Residents, Resident #28. The findings included: For Resident #28 the facility staff failed to provide nail care. Resident #28's face sheet listed an admission date of [DATE] and a readmission date of [DATE]. The Resident's [DIAGNOSES REDACTED]. Resident #28's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) 06/28/19 assigned the Resident a BIMS (brief interview for mental status) score of 8 out of 15 in section C, cognitive patterns. Section G, functional status, coded the Resident as needing extensive help of two person physical assist, in the area of personal hygiene. Resident #28's comprehensive care plan contained a care plan for self-care deficit. Interventions for this care plan include assist with oral care, nail care as needed. Surveyor observed Resident #28 on 09/05/19 at approximately 8:45 am. Surveyor observed Resident's fingernails to be long and somewhat jagged. Surveyor asked Resident #28 if staff cut his nails for him and he stated that they did not and that he gets his daughter to do it when she visits. Surveyor asked Resident if his nails being long bothered him and he stated that it did. Surveyor spoke with the DON (director of nursing) on 09/05/19 at approximately 11:30 am regarding nail care for Residents. DON stated that nail care is to be done during Residents bath or as needed. Surveyor asked the DON if nail care is documented when done, and she stated that it is not. Surveyor spoke with CNA (certified nurse's aide) #1 on 09/05/19 at approximately 11:45 am regarding nail care for Residents. Surveyor asked CNA #1 when nail care was done and CNA #1 stated we check them every day or so. CNA #1 also stated that Residents nails are cleaned/trimmed if needed when they are checked. Surveyor spoke with Resident's daughter on 09/06/19 at approximately 8:25 am. Surveyor asked Resident's daughter if the facility staff provided nail care for the Resident and she stated that they did not. The surveyor requested and was provided with a policy entitled Nail Care which read in part, Nursing staff will administer nail care in order to provide cleanliness and prevent infection. The concern of the facility staff not providing nail care for Resident #28 was discussed with the administrative team (administrator, DON, regional vice-president of operations) during a meeting on 09/05/19 at approximately 4:10 pm. No further information was provided prior to exit.

Based on observation, interview, and record review, the facility staff failed to ensure that a resident with pressure ulcers receives necessary treatment and services by monitoring an area to the right heel as ordered by the physician for 1 of 24 residents (Resident # 81). The findings included: Resident # 81 was a [AGE] year-old-male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 81 was reviewed on 9/5/19 at 1:48 pm. The most recent MDS (minimum data set) assessment for Resident # 81 was a 14-day scheduled assessment with an ARD (assessment reference date) of 8/27/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 81 had a BIMS (brief interview for mental status) score of 13 out of 15, which indicated that Resident # 81 was cognitively intact. Section M of the MDS assesses skin conditions. In Section M0210, the facility staff documented that Resident # 81 had one or more unhealed pressure ulcers or injuries during the look back period for the 8/27/19 ARD. The current plan of care for Resident # 81 was reviewed and revised on 8/27/19. The facility staff documented a focus area for Resident # 81 as, At risk for skin breakdown related to: decreased mobility, weakness, incontinence, [MEDICAL CONDITIONS], pressure ulcer on buttocks. Interventions included but were not limited to, Monitor affected area on right heel as ordered. Resident # 81 had orders that included but were not limited to, Monitor affected area on right heel, which was initiated by the physician on 8/26/19. On 9/5/19 at 4:11 pm, the regional vice president of operations, the facility administrator, and director of nursing was informed that the surveyor would like to observe Resident # 81's wounds during dressing changes on 9/6/19. On 9/6/19 at 10:50 am, LPN supervisor # 1 (licensed practical nurse) informed the surveyor that she was preparing to do dressing changes for Resident # 81. The surveyor informed LPN supervisor # 1 that she specifically wanted to observe that area to Resident # 81's right heel. LPN supervisor # 1 stated, He doesn't have an area on his heel. On 9/6/19 at 11:10 am, two surveyors was in the room with Resident # 81. Resident # 81 gave the surveyors permission to observe his right heel. Two surveyors observed small a dark red area to Resident # 81's right heel. On 9/6/19 at 1:55 pm, the surveyor interviewed LPN # 2. The surveyor asked LPN # 2 if the facility staff was providing treatment or monitoring any areas to Resident # 81's right heel. LPN # 2 stated, We are just taking care of his bottom, nothing on his foot. The surveyor and LPN # 2 reviewed the physician's orders [REDACTED]. LPN # 2 confirmed that Resident # 81 had orders to monitor affected area on right heel. The surveyor asked LPN # 2 if the facility staff had documented anything in Resident # 81's clinical record that supported that the facility staff was monitoring the affected area to Resident # 81's right heel as ordered by the physician. LPN # 2 and RN # 1 (registered nurse) reviewed Resident # 81's clinical record in the presence of the surveyor. RN # 1 stated, There is nothing documented that we are monitoring it. On 9/6/19 at 2:05 pm, the surveyor and LPN supervisor # 1 observed Resident # 81's right heel. The surveyor and LPN supervisor # 1 observed the small dark red area on Resident # 81's heel. The surveyor asked LPN supervisor # 1 to assess Resident # 81's right heel to determine if the heel was boggy. The surveyor observed LPN supervisor # 1 press on Resident # 81's heel. LPN supervisor # 1 stated, Yes it is boggy. The surveyor observed the progress notes for Resident # 81. The surveyor observed a Skin/Wound Note that was documented on 8/14/19 at 11:55 am. The skin/wound note contained documentation that included but was not limited to, .Blistered stage 2 noted to right heel measured a 4x4, foam tx (treatment) ordered. The surveyor observed the progress notes for Resident # 81. The surveyor observed a Skin/Wound Note that was documented on 8/26/19 at 3:26 pm, The skin/wound note contained documentation that included but was not limited to, .Monitor affected area to right heel. On 9/6/19 at 2:35 pm, the regional vice president of operations, administrator, and director of nursing were made aware that Resident # 81 had a blistered stage 2 documented in the clinical record and physician's orders [REDACTED].# 1 and LPN # 2 were not aware that Resident # 81 had an affected area to right heel or physician's orders [REDACTED]. The administrative team was also made aware that the facility staff reviewed the clinical record along with the surveyor and did not observe documentation that supported that the area to Resident # 81's right heel was being monitored as ordered by the physician. On 9/6/19 at 5:20 pm, the surveyor provided the administrative team the opportunity to ask questions and present additional information to dispute the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/6/19.

Based on observation, staff interview, and clinical record review, the facility staff failed to provide treatment consistent with the comprehensive care plan related to IV therapy for 1 of 24 Residents in the survey sample, Resident # 284. The findings included: The facility staff failed to ensure that Resident # 284 had PICC (peripherally inserted central catheter) line flush and dressing change orders. Resident # 284 was an [AGE] year-old-female that was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 284 was reviewed on 9/5/19 at 9:41 am. There was not a completed MDS (minimum data set) assessment for Resident # 284 during the time of the survey. The current plan of care for Resident # 284 was reviewed and revised on 9/3/19. The facility staff documented a focus area for Resident # 284 as, Resident is at risk for infection R/T (related to) PICC line, wound. Interventions included but were not limited to, Flush line as ordered, and IV procedures & site care per facility policies. Resident # 284 had orders that included but were not limited to, [MEDICATION NAME] Sodium Solution Reconstituted 2 GM (gram) Use 2 gram intravenously one time a day for wound infection until 09/10/19 23:59 (11:59 pm) Q (every) 24 hours, which was initiated by the physician on 8/30/19. The surveyor reviewed all physician's orders [REDACTED]. On 9/6/19 at 11:53 am, the surveyor interviewed the director of nursing. The surveyor asked the director of nursing for the facility policy that pertained to flushing and care if PICC lines. The director of nursing stated, I don't think we have a policy for that, but we get an order and we flush before and after antibiotic therapy. On 9/6/19 at 1:50 pm, the surveyor was in Resident # 284's room conducting a Resident interview. Resident # 284 showed the surveyor a single lumen PICC line in her right upper arm. The dressing over the PICC line was dated 8/28/19. The surveyor asked Resident # 284 if the nursing staff flushed her PICC line. Resident # 284 stated, Yeah, they always come back and flush it. On 9/6/19 at 1:52 pm, the surveyor conducted an interview with LPN # 2 (licensed practical nurse). The surveyor asked LPN # 2 if the facility flushed Resident # 284's PICC line before and after IV (intravenous) antibiotic therapy. LPN # 2 stated, Yeah, we should have an order. LPN # 2 and the surveyor reviewed the current physician's orders [REDACTED]. LPN # 2 stated, I don't see an order, but normally we do have an order for [REDACTED].# 2 stated, Yes, the treatment nurse does it once a week. The surveyor and LPN # 2 reviewed the physician's orders [REDACTED].# 2 confirmed that Resident # 284 did not have current orders for PICC line dressing changes. On 9/6/19 at 2:35 pm, the surveyor informed the administrator, director of nursing, and regional vice president of operations of the findings as stated above. The surveyor asked the director of nursing if the facility pharmacy had provided the facility with a policy on PICC line maintenance and usage. The director of nursing stated that she would look into it. On 9/6/19 at 5:20 pm, the director of nursing informed the surveyor that she did not locate a pharmacy policy on PICC line maintenance and usage. The surveyor provided the administrative team the opportunity to ask questions and provide information to dispute the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/6/19.

Based on observation, staff interview and clinical record review, the facility staff failed to ensure that residents who need respiratory care by maintaining oxygen equipment for 2 of 24 residents in the sample survey (Resident #38 and #24). The findings included: 1. The facility staff failed to store Resident #38's nebulizer mask in a plastic bag when not in use by the resident. Resident #38 was admitted to the facility on [DATE] with the following diagnoses, but not limited to [MEDICAL CONDITION], heart failure, dementia, anxiety disorder, depression and [MEDICAL CONDITION]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/3/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 9 out of a possible score of 15. Resident #38 was also coded as requiring extensive assistance of 1 staff member for dressing, personal hygiene and extensive assistance of 2 staff members for bathing. During initial tour of the facility on 9/4/19 at 11:15 am, this surveyor observed the nebulizer mask on lying on the table bedside of the bed. It was not in a plastic bag. On 9/5/19 at approximately 10 am, the surveyor observed the nebulizer mask lying on the bedside table. Again, the surveyor noted the nebulizer mask was not stored in a plastic bag. At 4:13 pm, the surveyor notified the administrative staff of the above documented findings. The surveyor asked the DON (director of nursing) how nebulizer masks were to be stored when not in use by the resident. The DON replied, It is supposed to be stored in a plastic bag when not in use. The surveyor asked for the facility's policy concerning storage of a nebulizer mask when not in use by the resident. DON stated, We don't have a policy on this but I would hold my staff to storing the nebulizer mask in a plastic bag when not in use by the resident. No further information was provided to the surveyor prior to the exit conference on 9/6/19. 2. The facility staff failed to maintain oxygen equipment for Resident #24. Resident #24 was readmitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/20/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 11 out of a possible score of 15. Resident #24 was also coded as requiring extensive assistance of 2 staff members for dressing and personal hygiene. During the initial tour on 9/4/19 at approximately 12:30 pm, the surveyor observed that the resident was receiving oxygen by nasal cannula. The surveyor also noted there was no date on the oxygen tubing or on the water bottle. On 9/5/19 at 11:00 am, the surveyor observed that the oxygen tubing and water bottle did not have a date on it. At 4:16 pm, the surveyor notified the administrative team of the above documented findings. The surveyor asked the DON (director of nursing) who changes the tubing and water bottle on the oxygen concentrator and how is this done. The DON stated, The night shift nurses are responsible for changing these out once a week. The staff will date the oxygen tubing and water bottle with the date they were changed. The surveyor asked the DON for a copy of the facility's policy on date and changing the water bottle and oxygen tubing. The DON stated, I don't think the policy states anything about this. The surveyor asked the DON what protocol she would use if she had found the above documented findings. The DON stated, They night shift is to change the oxygen tubing and water bottle once a week. They are supposed to date these items also. No further information was provided to the surveyor prior to the exit conference on 9/6/19.

Based on clinical record review, staff interview, and facility document review, it was determined that the physician failed to visit and assess skin conditions for 2 of 24 Residents in the survey sample, Resident # 79 and Resident # 81. The findings included 1. The physician or nurse practitioner failed to assess skin conditions that had been reported by nursing staff during follow up visits with Resident # 79. Resident # 79 was a [AGE] year-old-female who was originally admitted to the facility on [DATE], and had a facility readmission date of [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 79 was reviewed on 9/4/19 at 12:15 pm. The most recent MDS (minimum data set) assessment for Resident # 79 was a significant change assessment with an ARD (assessment reference date) of 8/20/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 79 had a BIMS score (brief interview for mental status) of 7 out of 15, which indicated that Resident # 79's cognitive status was severely impaired. Section M of the MDS assesses skin conditions. In Section M1040, the facility staff documented that Resident # 79 had a [MEDICAL CONDITION] during the look back period for the 8/20/19 ARD. The current plan of care for Resident # 79 was reviewed and revised on 8/23/19. The facility staff documented a focus area for Resident # 79 as, Risk for altered skin integrity due to change in mobility, diabetes, [MEDICAL CONDITION]. Interventions included but were not limited to, Treatment to right heel wound as ordered. Apply a foam dressing. Change as ordered. Resident # 79 had orders that included but were not limited to, Cleanse right heel wound with cleanser of choice, apply foam dressing every day shift Mon, Wed, Fri (Monday, Wednesday, Friday) for skin care, which was initiated by the physician on 8/22/19. On 9/4/19 at 1:13 pm, the surveyor was in the room with LPN # 1 and LPN # 3 while treatment was being administered to Resident # 79's right heel. The surveyor observed a round dark purple area about the size of a fifty-cent piece on Resident # 79's right heel. The surveyor observed an open area at the center of the wound. The surveyor reviewed the progress notes for Resident # 79. The surveyor observed a Skin/Wound Note for Resident # 79 that was documented on 8/21/19 at 23:14 (11:14 pm). The skin/wound note was documented as, Resident noted to have a broken blister to her R (right) heel area cleansed, [MEDICATION NAME] applied and message left for tx (treatment) nurse to eval and tx. Heelz-up in place per orders. A skin/wound note was documented on 8/22/19 at 13:13 (1:13 pm). The skin/wound note contained documentation that included but was not limited to, . New DFU ([MEDICAL CONDITION]) noted to right heel. Area is measured at 7x6 and is a serous fluid filled blister. Edge of blister is torn and a mod (moderate) amt (amount) of serous drainage is noted. On 9/4/19 at 2:35 pm, the surveyor spoke with the director of nursing regarding the area to Resident # 79's right heel. The surveyor informed the director of nursing of the observation of the dark purple area to Resident # 79's heel and the documentation that the facility staff made in Resident # 79's clinical record that the area on Resident # 70's heel was a [MEDICAL CONDITION]. The director of nursing stated, That not an area that I am comfortable with. We have a certified wound care nurse, and I leave those things up to her to take care of. The surveyor requested to interview LPN # 1 and LPN # 3. On 9/4/19 at 3:05 pm, the surveyor interviewed LPN # 1 and LPN # 3 in presence of the director of nursing and the survey team. LPN # 1 stated that she was filling in for the certified wound care RN who was on vacation. The surveyor asked LPN # 1 what type of wound was on Resident # 79's right heel. LPN # 1 stated, An old calloused area that has healed. The surveyor informed LPN # 1 of her observation of the wound to Resident # 79's right heel, which was a dark purple area on the heel with an open area in the center of the wound. The surveyor asked LPN # 1 if she had observed the wound as the surveyor had described. LPN # 1 agreed that she had observed the wound as described by the surveyor. The surveyor stated that the wound observed on Resident # 79's right heel was in a bony area, which normally was caused by pressure. LPN #1 stated, I agree in the presence of the survey team. The surveyor asked the director of nursing what criteria the facility went by to determine that the area on Resident # 79's right heel was a diabetic ulcer instead of a pressure ulcer. The director of nursing stated she would look into it further and report back to the surveyor. On 9/4/19 at 3:35 pm, the director of nursing provided the surveyor with a journal article with a highlighted portion, which was documented as, Any pressure ulcer on the foot of a person with diabetes is a [MEDICAL CONDITION]-as any traumatic wound, including a thermal or chemical injury. Vowden, P., Vowden K. (2015). [MEDICAL CONDITION] or pressure ulcer? That is the question. Diabetic Foot Journal 18: 62-66. The surveyor asked the director of nursing if this was the facility standard of practice for staging and classification of wounds. The director of nursing stated that this was the information that was utilized by the facility wound nurse who was certified in the area of wounds. The surveyor asked the director of nursing to provide the facility policy and standard of practice on wound staging and classification. On 9/5/19 at 8:42 am the director of nursing provided the surveyor with the facility Pressure Ulcer Policy and what the director of nursing identified as the facility standard of practice for staging wounds. The facility pressure ulcer policy contained documentation that included but was not limited to, .Assessment and treatment of [REDACTED]. 3. Differentiate the type of ulcer (pressure-related versus non-pressure related. Pressure ulcers are usually located over a bony prominence such as sacrum, heel) 6. The facility will notify family/responsible parties and the physician of any newly acquired or worsening pressure ulcers and treatments. The facility standard of practice for Pressure Ulcer Staging contained documentation that included but was not limited to, .Stage II The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. The director of nursing also provided the surveyor with a progress note from the nurse practitioner dated 9/4/19. The progress note contained documentation that included but was not limited to, .R (right) heel has some [DIAGNOSES REDACTED], no drainage to healing non-pressure diabetic ulcer with calloused upper edge. The surveyor asked the director of nursing had the nurse practitioner seen Resident # 79 to assess the area to the right heel prior to the surveyor bringing up a discrepancy in the classification of the wound. The director of nursing stated, No. The surveyor reviewed the physician progress notes [REDACTED]. The surveyor observed that the facility nurse practitioner had seen Resident # 79 on three occasions since the initial identification of the area on Resident # 79's right heel on 8/21/19. Upon review of the progress notes dated 8/26/19, 8/29/19, and 9/3/19, the surveyor did not observe any documentation that indicated that the facility nurse practitioner had assessed the area to Resident # 79's right heel. On 9/6/19 at 11:23 am, the surveyor interviewed the facility nurse practitioner. The surveyor asked the facility nurse practitioner had she assessed the area to Resident # 79's right heel prior to 9/4/19. The facility nurse practitioner stated that she had seen Resident # 79 on several occasions but did not assess the area to Resident # 79's right heel prior to 9/4/19. The facility nurse practitioner stated that she read the notes that had been documented on the area on Resident # 79's right heel and had worked closely with the facility's certified wound care nurse and trusted her judgement. On 9/6/19 at 2:35 pm, the administrator, director of nursing, and regional vice president of operations were made aware of the findings as stated above and of the issue that notification of a new area to Resident # 79's right heel was identified on 8/21/19 and treatment was started on 8/22/19. The facility nurse practitioner saw the resident on three occasions since the identification of the area to Resident # 79's right heel and did not assess the area until after the surveyor identified a discrepancy on 9/4/19. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/6/19. 2. The physician or nurse practitioner failed to assess Resident # 81 following the identification of a stage 2 pressure ulcer to the right heel. Resident # 81 was a [AGE] year-old-male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 81 was reviewed on 9/5/19 at 1:48 pm. The most recent MDS (minimum data set) assessment for Resident # 81 was a 14-day scheduled assessment with an ARD (assessment reference date) of 8/27/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 81 had a BIMS (brief interview for mental status) score of 13 out of 15, which indicated that Resident # 81 was cognitively intact. Section M of the MDS assesses skin conditions. In Section M0210, the facility staff documented that Resident # 81 had one or more unhealed pressure ulcers or injuries during the look back period for the 8/27/19 ARD. The current plan of care for Resident # 81 was reviewed and revised on 8/27/19. The facility staff documented a focus area for Resident # 81 as, At risk for skin breakdown related to: decreased mobility, weakness, incontinence, [MEDICAL CONDITIONS], pressure ulcer on buttocks. Interventions included but were not limited to, Monitor affected area on right heel as ordered. Resident # 81 had orders that included but were not limited to, Monitor affected area on right heel, which was initiated by the physician on 8/26/19. The surveyor observed the progress notes for Resident # 81. The surveyor observed a Skin/Wound Note that was documented on 8/14/19 at 11:55 am. The skin/wound note contained documentation that included but was not limited to, .Blistered stage 2 noted to right heel measured a 4x4, foam tx (treatment) ordered. The surveyor observed the progress notes for Resident # 81. The surveyor observed a Skin/Wound Note that was documented on 8/26/19 at 3:26 pm, The skin/wound note contained documentation that included but was not limited to, .Monitor affected area to right heel. The surveyor reviewed the physician progress notes [REDACTED].# 81 had been see by the physician on 8/22/19 and 8/29/19 and the physician did not document an assessment of the stage 2 area to Resident # 81's heel on either visit. On 9/6/19 at 2:35 pm, the regional vice president of operations, administrator, and director of nursing were made aware that physician did not assess the area to Resident # 81's right heel following the initial identification of the area on 8/14/19. The surveyor provided the administrative team the opportunity to ask questions and present additional information to dispute the deficient practice as stated above. No further information regarding this issue was presented to the survey team prior to the exit conference on 9/6/19.

Based on clinical record review, staff interview, and facility document review, it was determined that the facility staff failed to ensure that 1 of 24 Residents in the survey sample were free of unnecessary [MEDICAL CONDITION] medications, Resident # 25. The facility staff failed to ensure that Resident # 25 had a prn (as needed) [MEDICAL CONDITION] medication ordered that was limited to 14 days. Resident # 25 was an [AGE] year-old- female who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The clinical record for Resident # 25 was reviewed on 9/5/19 at 10:04 am. The most recent MDS (minimum data set) assessment for Resident # 25 was a quarterly assessment with an ARD (assessment reference date) of 6/20/19. Section C of the MDS assesses cognitive patterns. In Section C0500, the facility staff documented that Resident # 25 had a BIMS (brief interview for mental status) score of 2 out of 15, which indicated that Resident # 25's cognitive status was severely impaired. The current plan of care for Resident # 25 was reviewed and revised on 4/2/19. The facility staff documented a focus area for Resident # 25 as, At risk for adverse effects R/T (related to) psychoactive medication use: anxiety, dementia with behaviors, [MEDICAL CONDITION], depression, antipsychotic. Interventions included but were not limited to, Reduction in medication doses when indicated. Resident # 25 had current orders that included but were not limited to, [MEDICATION NAME] tablet 0.5 mg (milligram) Give 0.5 tablet by mouth as needed for agitation BID (two times daily), which was initiated by the physician on 5/2/19. The surveyor reviewed the entire clinical record for Resident # 25 and did not locate a documented rationale by the physician to indicate the need for prn [MEDICATION NAME] to exceed 14 days. On 9/6/19 at 2:35 pm, the administrator, the director of nursing, and regional vice president of operations was made aware of the findings as stated above. The director of nursing stated that she would review the chart further to identify any documented rationale to justify the use of prn [MEDICATION NAME] beyond 14 days. The facility policy on [MEDICAL CONDITION] Medication Documentation and Review contained documentation that included but was not limited to, .Procedure c. [DIAGNOSES REDACTED]. On 9/6/19 at 5:20 pm, the director of nursing informed the surveyor that she did not locate a documented rationale to support Resident # 25 having prn [MEDICATION NAME] for greater than 14 days. The surveyor provided the administrative team the opportunity to ask additional questions or provide information to dispute the deficient practice as stated above. No further information was provided to the survey team prior to the exit conference on 9/6/19.

Based on staff interview, clinical record review and facility document review the facility failed to provide dental services for 1 of 3 Residents, Resident #1 The findings included: For Resident #1 the facility staff failed to refer the Resident for dental services within 3 days after losing dentures. Resident #1 was admitted to the facility on 12/ /18. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) with an ARD (assessment reference date of 12/14/18 coded the Resident as 6 of 15 in section C, cognitive patterns. Section G, functional status, coded the Resident as 1/1 for eating. This is the equivalent of supervision/set up help only. This is an admission MDS. Resident #1's clinical record contained nurse's notes, which read in part 12/30/18 19:47 Nursing Note. Note Text: Resident c/o (complains of) pain to gums, upon inspection a small reddened area is noted to the front of gums. Called .(name omitted) at this time. n/o (new order) for [MEDICATION NAME] maximum strength q4hr (every 4 hours) PRN (as needed) to affected area as well as apply dentures only during meals. Staff will cont. to monitor for changes in health status, 12/31/18 18:21 Nursing Note. Note Text: Resident is seen this shift with dentures out of mouth except for meals. Gums are seen to be healing with no bleeding, redness, or soreness seen this shift. CB (call bell) and H2O within reach, 01/02/19 18:11 Nursing Note. Note Text: Resident noted to have dentures out at this time, with not redness or pain voiced, will cont. to monitor, and 01/12/19 12:49 Nursing Note. Note Text: (name omitted) NP (nurse practitioner) in to see Resident today new orders. Downgrade diet to Mechanical soft diet ground meat thin liquids & fortified food with all meals Surveyor spoke with the facility administrator, DON (director of nursing), regional director of operations, and SW (social worker) on 02/26/19 at approximately 1125 regarding Resident #1's missing dentures. DON stated that when Resident's dentures were reported missing, a grievance form was completed and Resident's room was searched. SW stated that Resident's son reported to another SW that Resident's dentures were missing on 01/07/19. SW stated that Resident's son had called and left a message for her on 01/11/19. Resident's room was again searched, along with all med carts. SW provided the surveyor with a copy of the grievance form with notes from the SW, which read in part 1/11/19: SSD (social services director) received a voicemail from .(name omitted), on 1/10/19, inquiring about Resident's lost dentures. SSD spoke with nursing re: the dentures. The med carts and Resident's room were searched again. The nursing supervisor contacted the nurse who had originally removed the dentures. She stated that she had placed the dentures in a denture cup and put it on the bedside table. The dentures were not found and 1/16/19: Resident's son .(name omitted) and his daughter, .(name omitted), arrived to the facility on [DATE], requesting to meet with SSD and LNHA (licensed nursing home administrator). They inquired about the lost dentures and were informed of the steps that had been taken to find them. Resident's son asked how top get them replaced. SSD told them that her dental insurance coverage would be checked and that an appointment could be scheduled with a local dentist for new dentures. Resident's son inquired about any other charges re: the dentures. SSD explained that she was M'Caid pending and how the cost would be covered if she was approved. LNHA told Resident's son that she would check with her supervisor re: reimbursement. Surveyor requested and was provided with a copy of facility policy entitled Dental Services, which read in part Policy: The facility will assist Residents in obtaining routine and 24 hour emergency dental care/services to meet the needs of each Resident. Facility will also be responsible for loss or damage of dentures in certain circumstances listed below and will make prompt referrals for Residents with lost or damaged dentures. 12. Facility will promptly, within 3 days, refer Residents with lost or damaged dentures for dental services. 13. If the referral cannot be made within 3 days, the facility will document what was done to ensure the Resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that lead to the delay. The concern of not referring Resident for dental services within 3 days was discussed with the administrative team during a meeting on 02/26/19 at approximately 1330. No further information provided prior to exit. This is a complaint deficiency.

Based on observation, staff interview and clinical record review, the facility staff failed to anchor an indwelling Foley catheter for one of 21 residents (Resident #17). The findings included: The facility staff failed to anchor Resident #17's indwelling Foley catheter. The surveyor reviewed Resident #17's clinical record 5/15/18 through 5/17/18. Resident #17 was admitted to the facility 5/1/18 with [DIAGNOSES REDACTED]. Resident #17's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 5/8/18 assessed the resident with a BIMS (brief interview for mental status) of 11 out of 15. Section H Bladder and Bowel was coded for indwelling catheter and incontinence as a 9- not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days. Resident #17's current comprehensive care plan had a focus area initiated 5/1/18 that stated resident requires urinary catheter due to urine retention. Interventions: Change cath (catheter) secure device as ordered. Resident #17's (MONTH) (YEAR) physician's orders [REDACTED]. The surveyor interviewed Resident #17 5/15/18 at 4:58 p.m. The surveyor observed the resident in bed with a Foley catheter drainage bag positioned on left side of the bed and in a privacy bag. Resident #17 stated the Foley had been put in during a hospital stay when she broke her hip. The surveyor asked the resident if the Foley catheter was secured to the leg and she stated she didn't know. The surveyor asked certified nursing assistant #4 to check for anchorage of the Foley catheter. C.N.A. #4 stated the Foley was not anchored and that they are not usually anchored. C.N.A. #4 stated the resident had orders for bladder training. C.N.A. #4 stated she would let the nurse know about the Foley. The surveyor informed the director of nursing of the above concern on 5/16/18 at 11:07 a.m. The DON stated the standard of practice was to anchor catheters. The surveyor requested the facility policy on urinary catheters. The DON informed the surveyor on 5/16/18 that the facility did not have a policy on catheters. The surveyor informed the administrator and the director of nursing of the catheter issue in the end of the day meeting on 5/16/18 at 5:33 p.m. and on 5/17/18 at 12:48 p.m. No further information was provided prior to the exit conference on 5/17/18.

Based on observation and staff interview, the facility staff failed to ensure that drugs were stored and labeled according to accepted professional principles. The findings included The facility staff failed to ensure that insulin was dated and stored appropriately in 1 of 6 medication carts. On 5/16/18 at 11:37 am, the surveyor inspected the medication cart on the 400 hall Medication cart on the 400 hall with RN (registered nurse) # 1. Upon inspection of the medication cart, the surveyor observed a Basaglar Kwikpen U-1 100unit/ml (milliliter) that had been opened and was not dated. RN # 1 reviewed medication and stated, I believe that they have used this one. The surveyor also observed a [MEDICATION NAME] 100 unit/ml that had been opened and was not dated RN # 1 stated, They are using this one. The surveyor observed a [MEDICATION NAME] 100 unit/ml pen unopened in medication cart. The label on the packaging states, Refrigerate until opening. The surveyor observed a vial of Humalog 100 unit/ml. The vial was not opened and on the medication cart. The label on the medication packaging states, Refrigerate until opening. On 5/17/18 at 1:15 pm, the administrative team was made aware of the findings as stated above. No further information was provided to the survey team prior to the exit conference on 5/17/18.

Based on observation, staff interview, resident interview, facility document review, and clinical record review, the facility staff failed to follow infection control guidelines for 1 of 21 residents (Resident #22) and failed to ensure PPE (personal protective equipment) was available for use in the laundry. An apron was not found in the laundry. The findings included: 1. The facility staff failed to follow infection control guidelines for Resident #22. The staff failed to ensure the 3 drawer cart at the entrance to the room contained hand sanitizer and facility staff failed to hand sanitize before and after entering Resident #22's room and failed to don PPE when entering the resident's room. The clinical record of Resident #22 was reviewed 5/15/18 through 5/17/18. Resident #22 was admitted to the facility 2/5/18 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #22 did not have a completed minimum data set (MDS) assessment. Resident #22's current comprehensive care plan identified a focus area for infection due to ESBL (Extended-Spectrum Beta-lactamase (ESBL)) in urine and UTI (urinary tract infection) initiated 5/9/18. Interventions: Isolation as ordered 5/9/18. The (MONTH) (YEAR) physician's orders [REDACTED].#22 had an order for [REDACTED].>The surveyor observed Resident #22 on 5/15/18 5:11 p.m. At the entrance to Resident #22's room was a 3-drawer cart containing PPE (personal protective equipment). The cart did not have any hand gel or hand sanitizer. On the doorframe was signage posted with instructions for Contact Precautions. Resident #22 was currently on isolation for ESBL. The surveyor observed Resident #22 on 5/16/18 at 8:42 a.m. Signage on the doorframe read STOP Contact Precautions Visitors must report to Nursing Station before entering. Perform hand hygiene before entering and before leaving room. Wear gloves when entering room or cubicle, and when touching resident's intact skin, surfaces, or articles in close proximity. Wear gown when entering room or cubicle and whenever anticipating that clothing will touch resident items or potentially contaminated environmental services. Use resident-dedicated or single use disposable-shared equipment or clean and disinfect shared equipment (BP (blood pressure) cuff, thermometers) between residents. The surveyor observed certified nursing assistant (CNA #1) coming out of the isolation room without any PPE or using hand sanitizer. When asked if she used PPE or hand gel, C.N.A. #1 stated she did not need to put any on because the infection is in her urine. Also on 5/16/18 at 8:46 a.m., the 3-drawer cart was checked for PPE. No hand gel in cart. No gloves in cart. C.N.A. #2 got two boxes of gloves. C.N.A. #2 donned a gown and gloves and entered the room but failed to sanitize her hands before entering the room. The surveyor observed C.N.A. #3 enter Resident #22's room to respond to the resident's call light on 5/16/18 at 9:15 a.m. C.N.A. #3 enter the room without using hand sanitizer or PPE. C.N.A. #3 did not do hand hygiene upon exiting Resident #22's room. The surveyor informed the director of nursing (DON) of the above observations on 5/16/18 at 9:30 a.m. The DON stated the staff should glove and gown at the door before entering and then remove and wash hands. The surveyor requested the facility policy on infection control for contact, airborne and droplet precautions. The DON informed the surveyor on 5/16/18 that the posted Contact Precautions was what she expected the staff to follow. The surveyor reviewed the Infection Control Policy on 5/16/18. Procedure: 1. Handwashing procedure, as described in the facility's Infection Control Policy shall be followed. 3. Staff shall be knowledgeable and adhere to all department and facility infection control policies. The surveyor informed the administrator and the director of nursing of the infection control concerns during the end of the day meeting on 5/16/18 at 5:33 p.m. and again on 5/17/18 at 12:48 p.m. No further information was provided prior to the exit conference on 5/17/18. 2. The facility laundry staff failed to use appropriate PPE (personal protective equipment) while handling laundry. The surveyor toured the laundry on 5/16/18 at 2:56 PM. Two laundry staff members (LSM I & LSM II) were interviewed during this tour. LSM I said the staff used PPE when transferring the laundry from barrels into the washers. LSM I told the surveyor the staff was using gloves and masks when transferring laundry. She told the surveyor they didn't have an apron--but tried to prevent the soiled laundry from coming into contact with their uniforms by holding it away from the body when loading a washing machine. LSM II, introduced as the environmental director, told the surveyor the laundry staff had never had an apron to use when moving dirty laundry. LSM II told the surveyor, An apron would be a good idea. On 5/16/18 at 4:00 PM the DON was informed of the surveyor's findings in the laundry. The DON said the laundry staff should be using all the appropriate PPE. The facility's infection control policy, reviewed and revised on (MONTH) 10, (YEAR), contained the following: Standard precautions - presumes all blood, body fluids, secretions, and excretions may contain transmissible infections .Wear a gown, that is appropriate to protect skin and prevent soiling or contamination of clothing On 5/17/18 the MD (maintenance director) was interviewed. He said all the staff in the laundry had been inserviced that morning about the appropriate use of PPE when handling soiled clothing and linens. The MD said an apron had been obtained and was now available for use in the laundry.

Based on observation, staff interview, and facility document review, the facility failed to ensure the dish machine in the kitchen was operating per the manufactures instructions. The findings included: The temperature of the dish machine wash cycle failed to reach the manufactures recommendation (155 degrees) when checked by the surveyor on 03/21/17. During initial tour of the facility on 03/21/17 the surveyor entered the kitchen at approximately 1:35 p.m. the surveyor and the DM (dietary manager) toured the kitchen. The DM was asked by the surveyor to run the dish machine so the temperatures could be checked. The DM and dietary employee #1 ran several cycles. However, the wash cycle only reached 140 degrees. The manufactures instructions printed on the outside of the dish machine read 155 degrees. The DM stated she would notify maintenance employee #1 and if was unable to be fixed they would wash the dishes by hand and contact the maintenance company. On 03/21/17 at approximately 2:35 p.m. the DM stated maintenance employee #1 had cut up the water temperature and dish machine was now reading 175 on the wash cycle. When checked by the surveyor the dish machine wash cycle temperatures ranged between 148-152 degrees. Maintenance employee #1 entered the kitchen area and stated he had cut the water temperature down after the reading of 175. Maintenance employee #1 again adjusted the water temperature and the reading on the dish machine reached a temperature of 155 on the wash cycle. The temperatures on the wash and rinse cycle were again checked on 03/22/17 at approximately 12:55 p.m. with no problems being identified. A review of the temperatures for the month of March revealed that on March 1 at the breakfast meal the wash cycle temperature only reached 150 degrees, maintenance was notified, and no other temperatures were recorded that were below the manufactures instructions. The facility provided the surveyor with a copy of the manufactures instructions for this dish machine. Per the manufactures specifications temperatures for the wash cycle should be155-160 and for the rinse cycle 180-195. The administrative staff was notified of the issues regarding the dish machine temperatures on 03/22/17 at approximately 3:45 p.m. and again on 03/23/17 prior to the exit conference. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interview and clinical record review, the facility staff failed to obtain a physician order prior to obtaining laboratory testing for 1 of 18 residents (Resident #6). The findings include: The facility staff obtained laboratory testing for a complete blood count (CBC) and a comprehensive metabolic panel (CMP) on 3/2/17 fro Resident #6 without a physician order. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current quarterly Minimum Data Set (MDS) with a reference date of 1/3/17 assessed the resident with a cognitive score of 5 of 15. The resident was assessed requiring supervision of 1 person for bed mobility, transfers, ambulation, toileting, bathing, and hygiene. The clinical record was reviewed. The physician had ordered to obtain a CBC and CMP on 3/8/17. The facility staff also obtained a CBC and CMP on 3/2/17. There was no physician order for [REDACTED]. The director of nursing was asked on 3/22/17 at 9:50 a.m. about the extra laboratory testing. The director of nursing stated the nurse had entered the laboratory testing twice in the computer orders and it was obtained on 3/2 and also 3/8. The administrator, director of nursing , and corporate nurses were informed of the findings during an end of the day meeting with the survey team on 3/22/17.

Based on staff interview and clinical record the facility staff failed to ensure 1 of 18 Residents (Resident #7) was free of a significant medication error in regards to diabetic management. The findings included. The facility staff failed to follow physicians orders in regards to insulin. The physician order [REDACTED]. The surveyor was unable to locate information to indicate this order had been followed consistently for the month of March 2017. The record review revealed that Resident #7 had been admitted to the facility 11/05/13. [DIAGNOSES REDACTED]. Section C (cognitive patterns) of the Residents significant change MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/05/17 included a BIMS (brief interview for mental status) summary score of 8 out of a possible 15. Section I (active diagnoses) included diabetes. The Residents CCP (comprehensive care plan) included the focus area Resident is at nutritional risk related to diabetes . Interventions included, but were not limited to, accucheck's as ordered and administer medications as ordered. Resident #7's current physician orders [REDACTED]. A review of the Residents eMARs (electronic medication administration records) for March 2017 revealed that on March 1 at 2100 (9:00 p.m.) the Residents BS was 351 the nursing staff documented they administered 15 units of insulin. However, there was no information in the clinical record to indicate the nursing staff had rechecked the BS after 1 hour. On March 9 at 1630 (4:30 p.m.) the facility nursing staff documented the Residents BS as being 387 and on March 17 at 1630 the BS was documented as being 521. The facility nursing staff documented they administered 15 units of insulin. Again the surveyor was unable to locate any information indicating the BS had been rechecked in 1 hour. On March 20 at 2100 the facility nursing staff had documented the Residents BS as being 449 and documented they had administered 15 units of insulin. The nursing staff had documented a follow up BS of 347 at 2200 (10:00 p.m.) However, this was still above 340 and the surveyor was unable to locate any information in the Residents clinical record to indicate what action if any the facility nursing staff had taken. On 03/22/17 at approximately 9:50 a.m. the surveyor shared the above information with the DON (director of nursing). The DON verbalized to the surveyor that she had seen that over the weekend and was unable to find any further information. The DON then added that the physician had been notified of the BS readings over the weekend. The administrative team of the facility was notified of the above findings during an end of the day meeting with the survey team on 03/22/17 and again on 03/23/17. No further information regarding the above was provided to the survey team prior to the exit conference.